Patients and Profits

One of the things I found difficult about being in full time private practice was the pressure to make money. Without getting too deep in the weeds, I'll say that the mechanics of paying the bills and funding a reasonable livelihood in medical practice isn't as obvious as many people think. Physicians mostly do ok, even if they practice at the fringes, and if they practice anything like mainstream medicine, and keep overhead manageable, they'll make a tidy living.

The rest of us? Well, making a good living is harder to do than it would seem. Chiropractors do ok, as do physical therapists. Nurse practitioners can do pretty well outside of being in a physician-led practice, but mostly they struggle. It's still very much a physician-centric economic model out there.

One thing I've observed is that there are very few "sweet spots" in which someone can practice without leaning toward going broke on the one hand, and having to push their practice hard toward opportunities for revenue generation on the other. In the latter case I've seen this emerge as everything from taking on questionable drug studies (for which practices get paid, usually per enrolled research subject), to pushing retail herbs and food supplements sold by the practice, to developing complicated treatment plans that require more patient office visits than are really necessary.

I found myself in that position many years ago. I didn't like it, and ended up allowing the practice to close in near-bankruptcy rather than come up with novel ways to milk patients for more money. Today, I practice part-time, and I have a full time university job, and those two engagements complement each other nicely. I make enough money to pay the bills, make improvements, and put a few bucks into my own pocket, but I don't have to constantly try to keep up: stuffing more patients into a tighter schedule, getting them to buy stuff through the practice, and all that other stuff that I'm sure many practitioners hate.

Corporate practice--and that's most health care these days--allows practitioners of all sorts a similar refuge from worry about the bottom line...but somebody is worrying about it, usually an executive physician, or businessperson, or administrator. Everything costs so much, and it needn't.

Recently, Mylan Pharmaceuticals has taken a PR hit associated with its price increase on epinephrine injectors, the EpiPen. Epinephrine, or adrenaline, is a natural substance that can be used in large doses to stop an allergic reaction in its tracks--and I mean fatal allergic reactions, like some people get from bee stings. Mylan says it needs to do this, but in fact there is no effective competition for this product, and for many people, it is absolutely necessary. Epinephrine is cheap, but the injector, which is automatic, has apparently become quite dear!

I saw an article in the Harrisburg Patriot-News by David Wenner last Sunday. In a sidebar he details some of the more rapacious price increases: Novocort up 3,000%, tetracycline and amitriptyline both up almost 1,000%, and Zestril up 800%, all over the last 5 years. Daraprim was a famous case, up 5,500%. An old drug for malaria (and sometimes AIDS), the license was bought by Turing Pharmaceuticals under CEO Martin Shkreli, who viewed it as an "investment." In fact every single one of the drugs in this paragraph is old, and was cheap, an example of how the free market should work, as better or newer drugs come along (and they aren't always the same thing!)

The companies say it's to pay for "research and development," but having been in this industry (I was involved in a large number of trials for AIDS drugs in the late 1990s and early 2000s) I can tell you it is not the case. This is an area well-researched, and in fact most of the excess profit goes to shareholders, where there's a lot of pressure to turn high short-term profits, and to marketing newer drugs to doctors. There is some research, but essentially, drug companies are turning people's dependence on these drugs into cash cows. And it is not for your benefit. (Although your 401k may see a few pennies of it.)

Some industry analysts have reported that this is really about trying to get more money out of insurance companies, as though it somehow doesn't touch the average consumer. That's a false comfort. Insurance money comes from somewhere--you.

We want medical miracles. I get that. But the fact is, most of this should cost us less than it does. In 2009 National Public Radio reported that in Japan, an MRI costs about $160 US. There are reasons for this, not just that the Japanese are somehow less greedy. Nevertheless, that's a difference of something like 1000% more expensive. Americans pay more for prescription drugs (even generics) than anyone else in the world (Wall Street Journal, 2015). Of course, they argue that the US effectively subsidizes research and development in other parts of the world. We simply spend more because there is money, and the opportunity for profit...and perhaps innovation.

Although as I tell my students, most "new" drugs are really what we call "me too" drugs: essentially drugs that do the same thing as many other drugs (Forbes, 2015).

It is more profitable to effectively market a new-but-only-slightly-new drug than it is to develop a truly remarkable breakthrough drug. A drug rep costs less than research, that's just a fact. In fact many drugs are completely interchangeable.

This just isn't right. I learned that making a killing on the backs of your patients is a hard, soulless road. I didn't go far down it. I could see what lay ahead. Earlier I discussed vaccination as a conflict between different American values, there, individualism versus communitarianism. A similar conflict poses itself to us with our health care, in that case, perhaps profit versus justice. Or, maybe innovation versus stagnation, although I doubt research would completely stop. I'd hope it would become more parsimonious, less a dog-eat-dog, sweaty race for the next grant, license, or patent.

I get it. Money's great. But it doesn't seem quite right, the way things are rigged now.

The Vaccine Debate

Ok, so now everyone's gathered together for the 2016 Summer Olympics in "Zika Central"--Brazil--where it's reported that some some 9000 people have been infected and about 900 of those have been pregnant women, according to the World Health Organization. Public health authorities report that the epidemic may have peaked, and researchers continue to look for a vaccine, even while municipal authorities apply their efforts at improved mosquito control, contraception use, and standing water mitigation.

So even though it's been a bit of a lazy summer while I've been on vacation, let's return to this matter of "The Vaccine Debate".

I'll summarize the debate as I see it. Public health experts, doctors, and nurses say that the full, recommended vaccination schedule is a must for both children and adults. They say that this or that disease was a "scourge" that "killed thousands" (or millions), and that anything other than full compliance is tantamount to child neglect, and also puts millions in our society at risk for the disease. People with concerns about vaccines aren't taken at all seriously: they are "anti-scientific", worry-worts, or just daft. Those who want to pick and choose vaccinations based on their risk estimates are dismissed, and usually coerced into compliance. The educational approach to patients, or parents with children, is to deliver the scientifically-blessed, officially-approved statistics on known side effects. These days, I've had some parents being asked to take their kids to another pediatrician if they aren't going to comply with full vaccination.

The other side? They argue that vaccines aren't "natural" (whatever that means), that immunization is a scheme developed by pharmaceutical companies to make money, and that vaccines cause a host of ills from autism to allergies--even though research tends to argue against that relationship. They magnify the risks of catastrophic-but-rare side effects in the published literature (including drug manufacturers' own package inserts), and ascribe time associations between a vaccination event and the subsequent diagnosis of things like autistic spectrum disorder, night terrors, and meningitis that may be mere coincidence. They also say that vaccines don't work, that the diseases vaccines protect against don't exist anymore or were never serious problems. The opinions of  celebrity "experts" hold more water than the facts of scientists for many of these folks.

Ok, stark enough difference?

If anyone reads this blog, it may be someone who isn't in either of those categories, and who wants to come back at me with how they are different, and how their opinion is more complicated than what I have presented.

I'd have to agree. After all, I talk to these folks in my practice, and have talked to people about this for 30 years, in the emergency room, in the hospital, in nursing homes, in general medical practice, and in my own holistic practice. Individuals aren't the issue. The general public discourse is. The "debate" that the media cover is between Vaccination Is A Universal Good and Vaccination Is A Universal Evil.

What rubbish. No discussion of an issue this complex is ever described by such a false choice.

I can kind of understand it from the perspective of the laypeople, celebrities, and holistic spokespeople who argue that it's a Universal Evil. After all, they're laypeople. They aren't trained scientists and clinicians. Although some are better-trained, and ought to know better.

But from the pro-vaccines folks? They should know better. They should have the sense to understand the complexities of this issue enough that their impulse to magnify risk, to frighten, and coerce should be resisted. 

As I noted previously, immunization works...mostly, and it works better to prevent some diseases than others, and there are biological reasons for that as well. Sometimes the results of a vaccination event are catastrophic, and parents will worry about that. What doesn't get said is that many of these diseases we immunize against aren't themselves that catastrophic. Examples include measles, mumps, and chicken pox. Moreover, some of these diseases may be mitigated by alternative efforts. For example, HPV (human papilloma virus) vaccine really does significantly reduce the likelihood of a woman developing cervical cancer later in life, but so does regular gynecological examination with a Pap smear.

In one lecture I give my students, I provide a detailed analysis of measles deaths that occurred prior to the development of measles vaccine in the early 1960s. The death rate was quite low, about 2 children in 500,000. Moreover, such deaths tended to be clustered among the very poor. This makes sense in light of Thomas McKeown's research in 1976 that most of the epidemics that were such "scourges" prior to modern immunization were actually on the decline because of improved nutrition and a rising standard of living. Although the British physician and medical historian tended to dismiss sanitation as another cause, other research strongly suggests that public infrastructure improvement to water distribution and sewage treatment also contributed to that decline.

By magnifying the real hazard, I tell my students, any parent with an internet connection can disprove that hazard, place it into a real context, and end up deciding that the doctor or nurse is a liar. That is a recipe for bad rapport and distrust, and when you have a bad rapport, and your patient thinks you're overstating the hazard, good luck with winning that parent or patient over with your otherwise scientifically-sound argument!

My concern is not with patients and parents who understandably hold onto worries about immunization, although many of their arguments are fraught with half-truths, myths, and urban legends. Indeed, it's hard to dismiss personal experience:

    "My friend took her child to get the MMR, and two months later he was diagnosed with autism!"

It's easy to see how this tale, retold a thousand times (among 100s of millions of vaccination events) can gain traction among ordinary folks with limited understanding of science. (It's a little less tolerable when told by people with such training who should know better.)

My concern is with health professionals who seem to evince some social authority from the seemingly hermetic "facts" presented by public health experts.

   "You must listen to me...for I am the authority, and you are a layperson (and an idiot)."

You health care workers out there who think you aren't represented by the above caption? Think again. I've seen it hundreds of times. It's a guaranteed rapport-killer.

So then why is this polarity in public discussion of the issue still the case? I think it has several causes. First, the constantly-evolving nature of biology and biological science unnerves us. Especially among clinicians, having something--anything--certain to bank on is a working day comfort. I've been doing this a long time: there's tons of uncertainty, tons of weird stuff with no easy answer. It's nice to be able to say "About this we are certain!"

Second, both corporatized and socialized health systems depend on thruput, that is, high production numbers. This means two things: 1) You can mitigate the potential disease risk of lots of people with a one-size-fits-all management plan. Mass immunization is such a plan. 2) Even if some people are greatly harmed, it will be few, and many more will be saved (so the argument goes). Individualized risk analysis and planning is time consuming and perhaps costly. It risks the loss of "herd" immunity if many people opt out. It is an essentially utilitarian analysis. In the words of Mr. Spock, "The needs of the many outweigh the needs of the few."

Third, there really is a corporate-capitalist motivation for mass immunization. It is true that some of the diseases we immunize against are really bad things. Rabies and tetanus and polio are good examples. Other diseases such as mumps, measles, and whooping cough can be deadly but usually aren't, and there's ample evidence that these are things that will pass. However, I can certainly understand the impulse to try to prevent them in our lovely children; who wants to see a child suffer? Nevertheless, there's a lot of financial gain to be had in finding less threatening diseases, like chicken pox, to immunize against. If we spent as much money making sure that all young children have enough healthy food to eat, rather than developing vaccines that may not really change the real health of our population (rotovirus vaccines are one example of this), evidence suggests the health gain overall would be immense.

But then there's no corporate profit in making sure poor kids eat well.

Families: Immunization does work, mostly, and most people don't have catastrophic outcomes. But don't depend on it alone, because many times it doesn't work (the flu). On the other hand, in some cases it can actually be life-saving (tetanus, rabies). Find yourself a clinician who can have a measured conversation about this choice. I have observed immunization to sometimes cause interference against an acting homeopathic remedy, but most of the time this can be repaired. Timing can matter. Immunizations can often be delayed or rescheduled without real harm. If you're looking for a list of recommended versus not-recommended vaccines, you won't find it here. Risk analysis is personal and individual.

Clinicians: Immunization isn't the panacea you've been taught. It kinda, mostly works, sort of. Scoring a win during a patient visit may feel good, but it's a small part of patient care. I know you get incentivized by the various insurers for vaccinating. But do know that you are settling for an aggregated health measure, rather than the health of the individuals in your practice. Be kind. People want answers and can live with uncertainty if it's discussed in context. Be happier than you have been with a negotiated settlement, like an alternative vaccination schedule. Be honest about social benefits (herd immunity) versus individual benefits (disease risk). You might be surprised by how many people share your view about the values of social good that may arise from individual choices. And if it's financial harm to the practice that frames your decision-making, consider the implications of that honestly.

And all you people on news programs, and blogs, and internet boards, and on TV? Go ahead an argue just as one-sidedly and vociferously as you have been--it's good for business! But know that you are just going around in circles with your opponents, locked in a pointless struggle that will yield no victor and just keep alienating the "other side." Don't imagine you are making the world a better place. You are just making the world a louder place, and mostly, you're missing the real opportunities to create change that would matter far more than whether or not some infant gets vaccinated against a sexually-transmitted disease like hepatatis B in the delivery room.

After all, it didn't work for me.

Reference
McKeown, T. (1976). The Role of Modern Medicine: Dream, Mirage or Nemesis? London: Nuffield Provincial Hospital Trust. ISBN 0-900574-24-0.